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Tuesday, June 08, 2010

Laymen find notion that more care and more expensive care can be worse as counter intuitive

A recent publication in the publication "Health Affairs" has evoked comments and some concern from advocates of comparative effectiveness research and admirers of the Dartmouth Atlas. See here for full text (pdf). A survey of "consumers" found a level of skepticism that is alarming to those folks who are in the business of claiming to know what aspects of medical care should be offered.

The idea that more care and more costly care gives inferior results to less care and less expensive care seem to be inconsistent with one's experience in a variety of areas. Many would relate to the experience of having a fly by night craftsman using cheaper materials doing a shoddy job at painting the house or doing household repairs. Few people believe that a cheaper car is better than an expensive luxury car. Think of a Mercedes versus those jokes made in Russia sold as cars. Most dental patients accept the notion that a root canal treatment followed by a crown is better than a dental extraction though the latter is much cheaper.

In the sixties what passed for treatment of acute myocardial infarction was cheaper than the much more effective and life saving treatment available now. In that instance more is better.

Until hip replacements became available patients with severe degenerative arthritis of the hip could look forward to years of limited mobility and pain. Now their lives are clearly improved but at a monetary cost considerably greater than the pain pills. In that instance more is better.

HIV-AIDS has been transformed from a rapidly debilitating and fatal illness to a chronic controlled illness with often very good quality of live.In that instance more is better.

I could easily generate a number of instances in which certain tests or procedures or medication use was/is not reasonably indicated and in the cases more is not better and I would agree that sometimes it is worse.

Surely, sometimes more is better and sometimes it is not. It is a more a matter of case law than the application of a universal general principle that cheaper is better. It is an empirical question regarding the particular intervention and the particular outcomes of interest. Sometime it may be but often the opposite seems to be the case. Many people seem to believe the lay adage that you get what you pay for even if that is not always right.

It is interesting that much of verbiage saying that more is not better comes from the progressive side of the spectrum of ideas and they will have their work cut out for them to disabuse the less informed of the naive notion that less is often not better.

An interesting parallel to this current day notion of there being too much spent on medical care ( not care for too many but too much care for some) is the economic nonsense that was spun out by the early Roosevelt administration. Their early theory as to why there was a recession/depression was that there was an overproduction of goods. Therefore,farmers had to cut back on production as did manufacturers. Interesting argument that the government tried to sell-people going hungry and the claim that farmers had to grow less.

The Dartmouth Atlas was spun far beyond what the evidence supported, for political ends. That’s where the problem lies, not with the project itself. The data need to be viewed within the limitations of the methods. The findings are relevant. The sheer enormity of the variation in cost says deviation from best practice is widespread. Many questions remain unanswered. One is why? What external factors drive the variation? Another is in what direction? The popular assumption is that the error is in the direction of over utilization but it could just as easily be the other way around. After all, that’s what the best quality data we have and a sampling of public opinion say.

DB's headline got it right: "Sometimes money buy better care"

To avoid confusion let me say that I am not against comparative effectiveness research.There are many instances of it being done now and previously without a governmental agency being put in charge of it.I am quite concerned with the power that a governmental CER agency will have and afraid that the well known phenomenon of regulatory capture will happen there.On the basis of the article it looks like a number of "medical consumers" also have some concerns.